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Wilderness Medicine SOAP Note

I complied this after a great NOLS course on Wilderness Medicine. Pack it in your rucksack and glove box! Share with anyone. I hope you find it helpful.

drchrisstout
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Wilderness Medicine SOAP Note

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  1. Scene: Safe? How many? How bad ? MoI for spine? EVAC Numbers: 800.508.1276, via AAC: 617.459.4200 (19745) Method of Injury: ________________________________________________________________________________________ Secure head/neck Look/Ask/Feel Patient ABCDE Stop + Fix SUB Name: __________________ Age: _______ Sex: M/F Chief Complaint:___________________________________________ Airway: ______ Breathing: ______ Circulation/Blood Sweep: _______ Disability/decision (If no MoI): __________ Env/ Exposure: _________ , Tattoo /Med-A-Lert, Head-to-Toe Exam revealed: _______________________________________________________ OBJ Vitals Time _________ __________ __________ Alert (Person/Place/Time/Event) /Verbal/Pain/Unresponsive Level of R ___ +O__ __ +O__ __ +O__ HR ___ x4= ___ ___ x4= ___ ___ x4= ___ RR ___ x2= ___ ___ x2= ___ ___ x2= ___ SkinColorTempMoisture _________ __________ __________ Include signs in the objective information. Make sure to also include symptoms in your notes as well. Sx: ___________________________________________________________________________________________________ Allergy: What: ____________________ Exposure? Y/N/Unk Reaction: _______________ Tx: ______________________ Medications: Name: __________________ For: ________________________ Last Time Taken: ____________________ Name: __________________ For: ________________________ Last Time Taken: _____________________ Name: __________________ For: ________________________ Last Time Taken: ____________________ Include dosage questions in the medications section: what, when, why, how much, did you have it today Hx: has this happened before, do you see a doctor on a regular basis for anything __________________________________________________________________________________________________ Food/ H2O: Last In/Out: ________________ What: ____________________ Output Color/Consistency: _____________ PG? Y/N/Unk Events: Recent Illness/Injury: events of the last 48 to 72 hours __________________________________________________ Focused SpineAssess: A+ O 3 /4 N/Y→Sober? N/Y→Free from distraction (pinch): N/Y→CirculationSensationMovement N/Y(in all 4 extremities)→Free of Spine Pain on palpation? Y/N (if yes to all then OK to move or release head) ASSESS: Based on MoI, Possible _______________________________ Possible ____________________________________ Possible _______________________________ Possible ____________________________________ PLAN, Tx: _______________________________________________________________________________________________ _______________________________________________________________________________________________ EVAC PLAN: ____________________________________________________________________________________________ ANTICIPATED PROBLEMS ______________________________________________________________________________ Tx Tips: Mild head injury: Amnesia A=O2,3,4→Nausia→Headache→Dizzy→Tired→Vomit OK to sleep, but say remember “fuzzy dinosaur” and then wake every 20 & ask what nonsense phrase was used Disoriented Irritable Combative head dark color behind ears/raccoon eyes/ might want to include evacuate with any decrease in LOR Sx as above Tx: monitor ABCs/backboard/elevate head 6-8”/EVAC Shock: A+O3,4 (unless otherwise explained)/^HR/^RR/pale+cool+clammy = Compensatory | O↓/agitated/HR↓/RR^/PCC = Decomp Cx: dehyd/ bleeding ___________ __ +O__ ___ x4= ___ ___ x2= ___ ___________ Reg/Irr : Strong/Weak Labored/Unlabored: Shallow/Deep

  2. Tx: find and treat the underlying cause control bleeding/maintain airway/calm/warm/elevate legs12”/fluids in extended situations CPR: 2 breaths; √ pulse; 30 comp+2br (rept 5x ); re √ pulse/resp Diabetes: Give sugar Abdominal EVAC? Abdominal pain+ S/Sx of shock+ Blood in vomit/,urine/feces+ Continuous pain>24O+ Localized pain, rigidity/guarding/tenderness, Pain on movement, Nausea/ vomit/ runs causing dehydration or lasting >720,Fever >1020, S/sx of PG (any of these individually should constitute an evacuation Musculoskeletal Test: Look/Ask/Feel→ CirculationSensationMovement→ Passive RoM → Active RoM → Bear weight?→ Usable HyRICE : Hydrate, Rest, Ice , Compress, Elevate. (NSAID) Tx for ‘unusables’ & fracture: Traction → normal position STOP Traction if resistance or marked increase in pain  Splint: rigid , padded. Immobilize joints above & below fracture ( Bones above & below joint injury)  Splinting: Simple/Padded/Adjustable/fingers-toes available  Monitor CirculationSensationMovement before and after splinting For open fracture: Irrigate and dress 1st! Start antibiotics! Tx for dislocations: Reduce ASAP+ Slow, steady traction-in-line. Relaxation is key+ HyRICE , work ROM 3x/day this should not be done before consulting a physician for a first time offender EVAC: ↓ CirculationSensationMovement, unusable & 1st time dislocations. Wounds Control bleeding Pressure & elevate; pressure on injury point Tourniquet:, loosen/ retighten if needed these can be left in place for 2 hours with out damage, if your are applying a tourniquet to a would you should be planning an evacuation for this pationt Prevent infection: clean it! Soap / H2O around wound Remove foreign matter; scrub abrasions if needed Pressure irrigate- only H2O Dress & bandage ;gaping>1/2” pack w/damp gauze Promote healing Puncture: leave and stabilize in place Remove if: in cheek, extremity, cold metal from body core EVAC: Impaled, Packed, Dirty/contaminated / bites, cosmetic, joints/genitals Heat Exhaustion: A+Ox4, HR/RR↑↓, SCTM: hot/red or pale/cool/clammy or dry Tx: cool pt/salty foods H2O/Electrolytes Stroke: Change in LoR (- sign) Disoriented Irritable Combative head, SCTM: red/hot/dry this can vary, may be red/hot/moist, pale/hot/dry. Tx: rapidly cool pt Life threatening: EVAC Cold DO NOT RUB frost-nip Mild:“the umbles” poor motor skills Moderate: ↓LoR (bad sign) uncontrolled shiver, ↑ umbles Sever: NO shiver, stupor/unresponsive, NO CPR Tx: warm/dry/no wind/warm food & drink/exercise if able, heat packs, hypo-wrap Frostbite Rewarm in 1060 H2O/ H2O in wrapped bottles in sleeping bag in groin, arm pits/or skin-to-skin Rev: 26 Feb 09 Chris E. Stout, http:about.me?DrChrisStout Life threatening: EVAC

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